Fiscal Year 2017–2018 Site Review Report for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
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Fiscal Year 2017–2018 Site Review Report for Access Behavioral Care—Denver and Access Behavioral Care—Northeast January 2018 This report was produced by Health Services Advisory Group, Inc., for the Colorado Department of Health Care Policy and Financing. Table of Contents 1. Executive Summary ........................................................................................................................ 1-1 Summary of Results ......................................................................................................................... 1-1 Standard V—Member Information .................................................................................................. 1-4 Summary of Strengths and Findings as Evidence of Compliance ............................................. 1-4 Summary of Findings Resulting in Opportunities for Improvement ......................................... 1-4 Summary of Required Actions ................................................................................................... 1-4 Standard VI—Grievance System ..................................................................................................... 1-5 Summary of Strengths and Findings as Evidence of Compliance ............................................. 1-5 Summary of Findings Resulting in Opportunities for Improvement ......................................... 1-6 Summary of Required Actions ................................................................................................... 1-7 Standard VII—Provider Participation and Program Integrity .......................................................... 1-8 Summary of Strengths and Findings as Evidence of Compliance ............................................. 1-8 Summary of Findings Resulting in Opportunities for Improvement ......................................... 1-9 Summary of Required Actions ................................................................................................... 1-9 Standard IX—Subcontracts and Delegation ..................................................................................... 1-9 Summary of Strengths and Findings as Evidence of Compliance ............................................. 1-9 Summary of Findings Resulting in Opportunities for Improvement ....................................... 1-10 Summary of Required Actions ................................................................................................. 1-10 2. Overview and Background ............................................................................................................ 2-1 Overview of FY 2017–2018 Compliance Monitoring Activities ..................................................... 2-1 Compliance Monitoring Site Review Methodology ........................................................................ 2-1 Objective of the Site Review ............................................................................................................ 2-2 3. Follow-Up on Prior Year's Corrective Action Plan .................................................................... 3-1 FY 2016–2017 Corrective Action Methodology .............................................................................. 3-1 Summary of FY 2016–2017 Required Actions ................................................................................ 3-1 Summary of Corrective Action/Document Review ......................................................................... 3-1 Summary of Continued Required Actions ....................................................................................... 3-2 Appendix A. Compliance Monitoring Tool ........................................................................................ A-1 Appendix B. Record Review Tools ...................................................................................................... B-1 Appendix C. Site Review Participants ................................................................................................ C-1 Appendix D. Corrective Action Plan Template for FY 2017–2018 .................................................. D-1 Appendix E. Compliance Monitoring Review Protocol Activities ................................................... E-1 Access Behavioral Care FY 2017–2018 Site Review Report Page i State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 1. Executive Summary The Code of Federal Regulations, Title 42—federal Medicaid managed care regulations, published May 6, 2016—requires that states conduct a periodic evaluation of their managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs) to determine compliance with federal healthcare regulations and managed care contract requirements. The Department of Health Care Policy and Financing (the Department) has elected to complete this requirement for Colorado’s behavioral health organizations (BHOs) by contracting with an external quality review organization (EQRO), Health Services Advisory Group, Inc. (HSAG). In order to allow for implementation of new federal managed care regulations published May 2016, the Department determined that the review period for FY 2017–2018 was July 1, 2017, through December 31, 2017. This report documents results of the FY 2017–2018 site review activities for both Access Behavioral Care—Denver (ABC-D) and Access Behavioral Care—Northeast (ABC-NE). For each of the four standard areas reviewed this year, this section contains summaries of the findings as evidence of compliance, strengths, findings resulting in opportunities for improvement, and required actions. Section 2 describes the background and methodology used for the 2017–2018 compliance monitoring site review. Section 3 describes follow-up on the corrective actions required as a result of the 2016–2017 site review activities. Appendix A contains the compliance monitoring tool for the review of the standards. Appendix B contains details of the findings for the appeals and grievances record reviews. Appendix C lists HSAG, BHO, and Department personnel who participated in some way in the site review process. Appendix D describes the corrective action plan process the BHO will be required to complete for FY 2017–2018 and the required template for doing so. Appendix E contains a detailed description of HSAG’s site review activities consistent with the Centers for Medicare & Medicaid Services (CMS) final protocol. Summary of Results Based on conclusions drawn from the review activities, HSAG assigned each requirement in the compliance monitoring tool a score of Met, Partially Met, Not Met, or Not Applicable. HSAG assigned required actions to any requirement within the compliance monitoring tool receiving a score of Partially Met or Not Met. HSAG also identified opportunities for improvement with associated recommendations for some elements, regardless of the score. Recommendations for requirements scored as Met did not represent noncompliance with contract requirements or federal healthcare regulations. Access Behavioral Care FY 2017–2018 Site Review Report Page 1-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY Table 1-1 presents the scores for ABC-D for each of the standards. Findings for requirements receiving a score of Met are summarized in this section. Details of the findings for each requirement receiving a score of Partially Met or Not Met follow in Appendix A—Compliance Monitoring Tool. Table 1-1—Summary of ABC-D Scores for the Standards # of # Score # of Applicable # Partially # Not # Not (% of Met Standards Elements Elements Met Met Met Applicable Elements) V. Member Information 12 11 6 5 0 1 55% VI. Grievance System 27 27 24 3 0 0 89% VII. Provider Participation 13 13 12 1 0 0 92% and Program Integrity IX. Subcontracts and 4 4 4 0 0 0 100% Delegation Totals 56 55 46 9 0 1 84% Note: While scoring related to individual, new federal requirements in the tool may indicate Met or Not Scored, all new requirements were scored Not Applicable in the total results; new federal requirements do not apply to CHP+ until July 1, 2018. *The overall score is calculated by adding the total number of Met elements and dividing by the total number of applicable elements. Table 1-2 presents the scores for ABC-D for the record reviews. Details of the findings for the record reviews are in Appendix B—Record Review Tools. Table 1-2—Summary of ABC-D Scores for the Record Reviews # of Score # of Applicable # # Not # Not (% of Met Record Review Elements Elements Met Met Applicable Elements) Appeals 30 27 27 0 3 100% Grievances 12 8 8 0 4 100% Totals 42 35 35 0 7 100% *The overall score is calculated by adding the total number of Met elements and dividing by the total number of applicable elements. Access Behavioral Care FY 2017–2018 Site Review Report Page 1-2 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY Table 1-3 presents the scores for ABC-NE for each of the standards. Findings for requirements receiving a score of Met are summarized in this section. Details of the findings for each requirement receiving a score of Partially Met or Not Met follow in Appendix A—Compliance Monitoring Tool. Table 1-3—Summary of ABC-NE Scores for the Standards # of # Score # of Applicable # Partially # Not # Not (% of Met Standards Elements Elements Met Met Met Applicable Elements) V. Member Information 12 11 7 4 0 1 64% VI. Grievance System 27 27 23 4 0 0 85% VII. Provider Participation 13 13 12 1 0 0 92% and Program Integrity IX. Subcontracts and 4 4 4 0 0 0 100% Delegation Totals 56 55 46 9